<%@ taglib uri="http://java.sun.com/jsp/jstl/core" prefix="c" %> 
<div id="add_record_div" name="add_record_div" class="modalDialog">
   	<div name="add_record_div_form" id="add_record_div_form"> 
	<a id="close_add_record" href="#close" class="close_add_record close" title="">X</a>	
   	
   	<form id="add_record_form" action="${pageContext.request.contextPath}/patient/add_record" method="POST">
	<input type="hidden" name="patient_id" value="${patient.patient_id}" /> 
	
	<!-- MEDICAL HISTORY -->
	<div id="medical_his_div">
	<h3>ADD MEDICAL RECORDS</h3>
		<table>
		<c:forEach var="tbl_med_his" items="${medHisQuestionList}" >
			<tr><td>Question: ${tbl_med_his.tbl_maintenance_description}
					<input type="hidden" value="${tbl_med_his.tbl_maintenance_description}" name="question" />
			</td></tr>
			<c:choose>
				<c:when test="${tbl_med_his.code_table_value=='2'}">
					<tr><td>Physical Ailments:</td></tr>
					<c:forEach var="tbl_physical" items="${physicalAilmentList}">
						<tr><td><input type="checkbox" name="physical_ailments" value="${tbl_physical.tbl_maintenance_description}"> ${tbl_physical.tbl_maintenance_description}</td></tr>
					</c:forEach>
				</c:when>
				<c:when test="${tbl_med_his.code_table_value=='8' && patient.sex=='M'}">
					<tr><td><input type="text" disabled="disabled" name="answer" value="-" /></td></tr>
							<input type="hidden" name="answer" value="-" />
				</c:when>
				<c:otherwise>
					<tr><td><input type="text" name="answer" /></td></tr>
				</c:otherwise>
			</c:choose>
		</c:forEach>
		</table>
	</div>
	
	
	<!-- DENTAL HISTORY -->
	<div id="dental_his_div">
	<h3>Dental History</h3>
		<input type="checkbox" name="fluoride_treatment" value="true">Fluoride Treatment<br>
		<input type="checkbox" name="orthodontic_treatment" value="true">Orthodontic Treatment<br>
		<input type="checkbox" name="pulp_therapy" value="true">Pulp Therapy<br>
		<input type="checkbox" name="temporo_mandibular" value="true">Temporo Mandibular<br>
		<input type="checkbox" name="periodontal_therapy" value="true">Periodontal Therapy<br>
		<input type="checkbox" name="dental_surgery" value="true">Dental Surgery<br>
		<input type="checkbox" name="extraction" value="true">Extraction<br>
	</div>
	
	<!-- CLINICAL EXAM -->
	<div id="clinic_exam_div">
	<h3>Clinical Examination</h3>
		<table>
			<tr>
				<td>Gingival Color</td>
				<td><input type="radio" name="gingival_color" value="pink" />pink</td>
				<td><input type="radio" name="gingival_color" value="bright red" />bright red</td>
				<td><input type="radio" name="gingival_color" value="pale" >pale</td>
			</tr>
			
			<tr>
				<td>Consistency of gingival</td>
				<td><input type="radio" name="consistency_of_gingival" value="firm" />firm</td>
				<td><input type="radio" name="consistency_of_gingival" value="hyperplastic" />hyperplastic</td>
				<td><input type="radio" name="consistency_of_gingival" value="smooth" />smooth</td>
			</tr>
			<tr>
				<td>Tounge</td>
				<td><input type="radio" name="tounge" value="normal" />normal</td>
				<td><input type="radio" name="tounge" value="coated" />coated</td>
				<td></td>
			</tr>
			<tr>
				<td>Oral Hygiene</td>
				<td><input type="radio" name="oral_hygiene" value="good" />good</td>
				<td><input type="radio" name="oral_hygiene" value="fair" />fair</td>
				<td><input type="radio" name="oral_hygiene" value="bad" />bad</td>
			</tr>
			<tr>
				<td>Lymph Nodes</td>
				<td><input type="radio" name="lymph_nodes" value="not palpable" />not palpable</td>
				<td><input type="radio" name="lymph_nodes" value="palpable" />palpable</td>
				<td></td>
			</tr>
		</table>
	</div>
	
	<!-- OCCLUSION -->
	<div id="occlusion_div">
	<h3>Occlusion</h3>
		<table>
			<tr>
				<td>Class I</td>
				<td>div: <input type="text" name="class_1" /></td>
			</tr>
			<tr>
				<td>Class II</td>
				<td>div: <input type="text" name="class_2" /></td>
			</tr>
			<tr>
				<td>Class III</td>
				<td>div: <input type="text" name="class_3" /></td>
			</tr>
		</table>
	</div>
	
	<!-- ANXILLARIES -->
	<div id="anxillaries_div">
	<h3>Anxillaries</h3>
		<table>
			<tr>
				<td>Bleeding Time</td>
				<td><input type="text" name="bleeding_time" /></td>
			</tr>
			<tr>
				<td>Blood Pressure</td>
				<td><input type="text" name="blood_pressure" /></td>
			</tr>
			<tr>
				<td>Radiographic Interpretation</td>
				<td><input type="text" name="radiographic_interpretation" /></td>
			</tr>
			<tr>
				<td>Clotting Time</td>
				<td><input type="text" name="clotting_time" /></td>
			</tr>
			<tr>
				<td>Blood Sugar</td>
				<td><input type="text" name="blood_sugar" /></td>
			</tr>
		</table>
	</div>
	
	<!-- OTHER INFORMATION-->
	<div id="other_info_div">
		<h3>Other Information</h3>
		<table>
			<tr>
				<td>Chief Complaint</td>
				<td><input type="text" name="chief_complaint" /></td>
			</tr>
			<tr>
				<td>Diagnosis</td>
				<td><input type="text" name="diagnosis" /></td>
			</tr>
		</table>
	</div>
	<label id="" class="button mouseout_button" onClick="submitForm('add_record_form')">Save</label>
	</form>
	</div>
</div>